Statement and considerations for the remote delivery of pulmonary rehabilitation services during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has had an overwhelming impact on people’s lives and healthcare delivery across the world. Prioritisation of NHS resource during the first UK national lockdown led to a temporary suspension of ‘non-essential’ services. Conventional face-to-face PR programmes were widely suspended in order to protect vulnerable groups and many staff redeployed in order to support the care of those acutely unwell. Currently, the majority of patients eligible for PR are still recommended to shield or limit their exposure by accessing online or remote consultations with healthcare professionals (Department of Health & Social Care 2020a). Though the majority of services have restarted in some form, many have once again been faced with redeployment of staff during the 2nd wave and many rehabilitation spaces or venues remain unavailable (Chartered Society of Physiotherapy (CSP) 2020a).

Technology-enabled remote delivery of non-urgent healthcare services has played a significant role in the resumption of non-urgent services in the NHS. Whilst this has facilitated the delivery of components of care during the pandemic for many, it is inevitable that some will be significantly disadvantaged by the movement to digital services.

It is estimated that 7% of UK households are without internet access, and 10.7 million people in the UK have limited to no digital skills (Majeed et al. 2020). In a recent survey of PR service-users, of 170 survey respondents, 31% reported having never accessed the internet, and 29% reported no interest in accessing any component of PR digitally (Polgar et al. 2020). The spectrum of digital literacy of health care professionals expected to use potentially unfamiliar digital tools and technology must also be acknowledged. The rapid shift to remote delivery has highlighted the need for identification of training need and support in this regard. Willingness and acceptance of telehealth by staff is required in the provision of an effective remote service (Smith et al. 2020).

The efficacy of PR in improving health related quality of life (HRQoL) and exercise capacity in chronic respiratory disease populations is undisputed, and the need for PR remains high priority (McCarthy et al. 2015; Dowman et al. 2014; Lee et al. 2017). The continually evolving circumstances and associated measures to reduce transmission of the novel virus have seen the rapid adaptation of PR services in the pursuit of continuing to serve our chronic lung disease population. The prevention of hospital admissions is of utmost importance not only in terms of an individual’s health, but also in minimising the burden on our NHS and risk of COVID-19 transmission. COVID-19 has imposed an unprecedented challenge on accessibility to PR, further to the well-established existing issues with access, uptake and adherence (Rochester et al. 2015; Royal College of Physicians 2018). The World Health Organisation (2020) recommended the use of tele-rehabilitation where feasible during the pandemic; indeed, the role and opportunity to evaluate remotely delivered PR has been highlighted (Houchen-Wolloff & Steiner 2020; Jácome et al. 2020).

Remote physiotherapy is considered to comprise any means of service provision whereby the patient is remote from the practitioner; including email, SMS (short message service), telephone, web-based platforms or apps, and video conferencing (CSP 2020b). In the context of PR, there is an existing body of evidence for home-based rehabilitation encompassing both digital and non-digital platforms, which has recently been summarised by Singh et al. (2020a). Though several studies demonstrated similar improvements in exercise capacity and health related quality of life (HRQoL) as observed in centre-based PR (public relations), all of the studies identified involved thorough face-to-face pre- and post-PR assessment; limiting the applicability of findings due to the restrictions faced by many services at this time.

In the unprecedented and ever-evolving circumstances we find ourselves in, we must continue to prioritise the safety and well-being of our patients and staff in the provision of adapted interventions that focus on improving HRQoL (health-related quality of life) in our chronic lung disease population. This document draws on the experience of UK PR professionals, highlighting examples of innovative practice seen during the pandemic, with the aim of supporting services to deliver the best possible care under varied restrictions. It is hoped that evaluation of remotely delivered PR during this time will assist in the pursuit of improving access to PR longer-term.

Methods of guidance development

An online survey ACPRC Pulmonary Rehabilitation provision during COVID-19 and beyond! (delivered via SurveyMonkey) was developed by members of the ACPRC committee with an

interest in PR, with the aim of scoping current practice and shaping this document. Inspired by queries received from ACPRC members during the pandemic, questions were developed with a view to scoping staff provision, extent and mode of service delivery, use of video-conferencing and associated challenges, and responsibility for post-COVID-19 rehabilitation. The survey was conducted between 20th September and 6th October 2020, and was publicised and disseminated via Twitter using the @theACPRC handle with the aim of promptly reaching as many respiratory physiotherapists working in PR services in the UK as possible.

It was requested that 1 team member completed the survey on behalf of their PR service, and consent was assumed based on completion of the survey. A summary of the responses from the 46 participants are appended (Appendix 1).

A call of interest to contribute to the development and review this document was communicated via email to the ACPRC editorial board and respiratory leaders’ group late September 2020, seeking to recruit experienced respiratory physiotherapists working in PR. 12 reviewers were identified and subsequently 2 online meetings were held on 15th and 16th October 2020 to discuss the scope and contents of the document with those able to attend. Subsequently, the draft document was developed and 2 rounds of reviews were conducted over October and November 2020.

Furthermore, a rapid literature review was undertaken in order to inform practice and to identify any additional grey literature or relevant studies published following the release of the BTS guidance documents (Gardiner et al. 2020a; Singh et al. 2020a). The search terms used were: pulmonary rehabilitation, respiratory rehabilitation, tele-rehabilitation, remote delivery, and virtual.

Adapted models of service delivery

It is recognised that the ability to deliver PR in the current circumstances is highly dependent on various local factors in addition to government imposed national and local guidelines. It is essential that PR services continue to adhere to the most up-to-date government guidance in order to minimise the risk posed by COVID-19 to both patients and staff (Department of Health & Social Care 2020b). The impact of the pandemic has led to the need for adapted, in some cases untested, models of service delivery and prioritisation. Further, services have already and will continue to be required to adapt to the varying levels of restrictions imposed for the foreseeable future. Although some evidence-based models of remote service delivery were developed and in use prior to the pandemic (including forms of tele-rehabilitation), these models may need to be adapted or modified according to current circumstances. An example of service adaptation in response to COVID-19 is available here (Nottinghamshire Healthcare NHS Foundation Trust 2020): https://www.nottinghamshirehealthcare.nhs.uk/latest-news/covid19-drives-digital-innovation-in-pulmonary-rehab-3628.

At the time of completion of the survey, 33% of participating services reported offering the exercise component of PR face-to-face within the patient’s home, and 26% in a hospital or community site.

• Where feasible to do so, restarting face-to-face services is recommended due to the robust evidence of efficacy and benefits of face-to-face contact. The BTS have produced guidance regarding the safe resumption and continuation of respiratory services (BTS 2020) and the delivery of face-to-face PR during the pandemic (Singh et al. 2020a, pp. 3–6).

• Where it is feasible, the delivery of outdoor exercise testing and/or exercise training may be considered based on local policy and procedures, including risk assessment. Consideration must be given to social distancing measures, weather limitations, and individual participant risk assessment.

We recommend the following model of service prioritisation for those able to offer limited face-to-face services:

Priority 1: Exercise testing (assessment) with prioritisation of high-risk groups* as required.

As able then add:

Priority 2: Exercise testing (assessment) with all groups (usual prioritisation protocol).

As able then add:

Priority 3: Exercise component with prioritisation of high-risk groups* as required.

As able then add:

Priority 4: Exercise component with all groups (usual prioritisation protocol).

As able then add:

Priority 5: Education component (complete face-to-face PR service).

Many services are now offering various methods of remote delivery to both ensure meeting increased demand and, in some cases, services are still unable to provide any face-to-face option. Subject to appropriate risk management procedures, remote delivery options may be used for triage, assessment, exercise and education components of PR (CSP 2020b).

Survey participants reported using supervised ‘virtual’ rehabilitation via video-conferencing (50%), unsupervised exercise programmes with telephone support (63%) or app/webbased platform (50%) for remote delivery. Risk mitigation covering inclusion and exclusion criteria is considered within the Governance section of this document. The remote delivery of the separate components of PR (assessment and re-assessment, exercise and education) will be covered in further detail in part 2.

It is essential to evaluate remote delivery options following implementation to inform future service delivery planning, minimising health inequalities, supporting case for technological hardware and software, identifying training needs of staff and demonstrating cost (CSP 2020b).

Considerations in setting up a remotely delivered service:

• Alignment with BTS quality standards for PR (BTS 2014).

• Use of existing products and services provided by your trust where possible. Consult your local IT service in the consideration of a new product or service.

• Any new forms of delivering care should go through local governance procedures; including quality, data protection, and equality impact assessment.

• Consider the digital literacy, skills and confidence of staff, and the provision of support to ensure competence to safely and effectively utilise digital tools.

• Workspace and equipment required to safely and effectively deliver the service.

• Risk versus benefit of providing service, with consideration of feasibility and sustainability.

• Information and guidance for staff (including standard operating procedure).

• Communicating changes to service with internal and external stakeholders.

Governance

Risk assessment/mitigation

It is essential to regularly review the UK government website to ensure that service delivery continues to adhere to the latest guidance and associated measures to reduce transmission of COVID-19 (Department of Health & Social Care 2020b): www.gov.uk/coronavirus.

Face-to-face services

If any components of service delivery are being provided face-to-face, a COVID-19 screening protocol is essential to reduce risk of transmission. The protocol should reflect the latest guidance for households with a possible or confirmed COVID-19 infection (Public Health England 2020) and local guidance, to include:

• Contacting the patient one or 2 days before the planned face-to-face session to screen for patient and/or household member symptoms of COVID-19.

• Acute symptom screening on arrival.

• Advice to be given if the patient or household member has symptoms of COVID-19.

• Advice to be given to the patient regarding the safe resumption of face-to-face contact. The BTS have produced guidance regarding the restarting conventional PR and associated risk mitigation procedures (Singh et al. 2020a).

Remotely delivered services

If any components of service delivery are being provided remotely, comprehensive risk assessment must be conducted in line with local policy and procedures. Standard operating procedure (SOP) for any pre-existing remotely delivered components should be reviewed and updated (an appendix could be used to document this). Many PR services are offering both digital and non-digital modes of remotely delivered care. Identification and mitigation of potential hazards associated with each type and model of remote service delivery offered must be considered.

The BTS has produced a checklist of safety precautions for remotely supervised interventions (Singh et al. 2020a). Important considerations in mitigating risk associated with the delivery of remotely supervised PR include:

• Individual patient risk assessment; Table 1 details recommended inclusion and exclusion criteria.

• Obtain informed consent (verbal or written) to remotely supervised PR ensuring the patient has a clear understanding of the intervention and associated risks and benefits. An example consent form for remotely supervised PR is appended (Appendix 2).

• Ensure the patient has a clear understanding and awareness of potential adverse events. Ensure to include procedure for medical emergency during remotely supervised contact within your SOPs. This should include appropriate review during and after the session to ensure the patient’s well-being in the case of observed adverse events or sudden unexpected video disconnection.

• Ensure to provide the patient with clear information and instructions regarding the use of the video-conferencing/other digital platform. An example patient information document (Microsoft Teams) is appended (Appendix 3).

• Where possible, providing the patient with an opportunity to do a ‘test run’ prior to commencing their programme is advisable. Ensure to familiarise the patient with the ‘speaker view’ function of the video-conferencing tool to facilitate optimal visualisation of the instructing clinician.

• In accordance with local privacy and data protection policy, ensure to advise patients against recording their group session as doing so in the absence of explicit consent from all members of the group would be considered a breach of confidentiality (NHSX 2020a).

• Consider the use of a patient self-assessment checklist to prompt review of symptoms, preparation of equipment and environment, and access to support, prior to starting a session. An example checklist of this is appended (Appendix 4).

• Where remote monitoring is being used, patients should be provided with equipment that has been appropriately maintained and checked, as well as quarantined/cleaned in line with local infection control policy. Patients should be provided with the relevant guidance and instructions, and technique checked prior to commencing their programme to ensure safe and effective use.

• Risk assessment of available workspace and equipment to be used for the delivery of remotely supervised interventions is essential.

• Consideration must be given to the screen size of the device to be used by the clinician (for example, laptop, desktop) in assessing staff to patient ratio requirement for group interventions. Dependent on individual patient risk assessment, a ratio of 1:4 may be appropriate when using a laptop, whereas 2:8 may be optimal in using a large TV screen, enabling one member of staff to focus on monitoring.

• The use of headsets may be beneficial in optimising audio quality.

• Consideration must be given to the background environment seen and heard by patients in order to ensure privacy, avoid unwanted distractions, and optimise instructive interaction with patients. Avoid windows/mirrors being in view, and take appropriate action to minimise any significant background noise. The volume of any music used in exercise sessions must be assessed to ensure the instructing clinician can be heard clearly by all; with consideration for any participants with any hearing impairment.

• Training needs of staff expected to use video-conferencing (and/or other digital platforms) must be assessed and appropriate support provided.

• Consideration of individual risk assessment is essential in grouping patients for exercise interventions based on monitoring requirements.

• In instances where the ability to meet service demand is significantly impacted due to imposed restrictions resulting in breach of maximum waiting times (BTS 2014), this must be logged on the local trust’s risk register in line with local policy and procedure.

• A health inequalities impact assessment is recommended in order to support the identification of approaches to reduce discrimination and improve access.

Table 1: Recommended inclusion and exclusion criteria for remotely supervised exercise testing and exercise component of PR.

Inclusion • Access to device capable of supporting the video-conferencing platform and reliable internet connection. • Adequate digital literacy and competence to use video-conferencing and email, or reliable support of digitally competent family member/carer. • Able to safely follow instructions in English or be supported by family/carer or remote interpreting service. • Safe environment within home to perform exercise test/exercise programme. • Able to mobilise and use any home exercise equipment safely and independently. • Consents to participate in remote exercise testing/virtual PR programme. • Able to provide informed consent and report adverse events. Exclusion • Significant unstable cardiac or other disease that would make exercise unsafe or prevent programme participation. • Cognitive impairment with inability to follow instructions safely. • Significant sight or hearing impairment (individual risk assessment where indicated). • Impaired balance with risk of falls without supervision. • Identified as high risk of exertional desaturation <90% (for example, resting SpO2 ≤92% or home oxygen user, pulmonary fibrosis, post-acute exacerbation) and unable to remotely monitor pulse oximetry.

Please note that this is intended as a guide only; individual risk assessment as per usual protocols is required.

Workforce

Many PR services faced re-deployment of staff into the acute hospital and rapid discharge sectors to support the first wave of COVID-19. This came with increasing demand on hospital services and the drive to discharge as many suitable patients as possible back into the community setting to avoid the NHS being overly burdened. Though required at the time, the recommended temporary suspension of face-to-face PR services caused significant impact for the staff involved. Many staff were re-deployed to areas and specialities outside of their usual remit and/or working unusual shift patterns in highly stressful environments. Although staff have pulled together to support the wider NHS team in acute service delivery, the significant impact on morale and staff well-being must be recognised. Trusts have been pro-active in supporting staff with increased access to well-being resources and counselling support (NHS Leadership Academy 2020): https://people.nhs.uk. Teams need to consider easy access to well-being support of all staff who have worked through the pandemic, regardless of the role they have provided.

This impact must continue to be considered as the UK endures a second wave of COVID-19, which is coinciding with flu season and winter pressures. Services have also to contend with the significant impact this disruption to services has caused on waiting lists and waiting times for PR. Some may face further redeployment in the future; services need to plan for this and how they can reduce this impact in the future. The utilisation of the existing workforce in a different way can go a long way in supporting the reduction of the backlog.

Many services are receiving referrals for post-COVID-19 patients; 57% of survey respondents reported being responsible for the delivery of a post-COVID rehabilitation service. Dependent on the provision of additional resource, the potential impact on existing capacity and demand issues must be considered. Guidance on the delivery of post COVID-19 rehabilitation using an adapted PR approach has been produced by the BTS (Singh et al. 2020b).

PR teams also need to consider the sustainability of services and how different tiered lockdown restrictions may impact on service delivery. Social distancing measures have reduced throughput of patients in face-to-face programmes. In some instances, remotely delivered services may play a role in managing service demand and reducing waiting times. As tier restrictions increase, some services may face loss of indoor venues; for example, in the Liverpool City region, all gyms and leisure centres were closed including those used for local PR services during tier 3 restrictions (prior to the second national lockdown). The provision of remotely delivered PR, home visits, and group outdoor activities (as weather permits) needs to be considered (and regularly reviewed) at a local level based on what can feasibly be offered by the service within the area they serve, as and when restrictions are updated.

Services offering any remotely delivered components of PR must ensure staff are suitably digitally literate and competent in using digital platforms used by the trust. Appropriate training and support needs to be provided (NHSX 2020b): www.nhsx.nhs.uk/covid-19-response/technology-nhs/web-based-platform-which-offers-video-calls-services/.

Upskilling existing support staff within services is a practical approach in supporting the continued service delivery. This serves to strengthen the workforce and ensure services can continue to support increasing numbers of patients. Developing skills and expanding capabilities within the existing workforce will create more flexibility, boost morale and support career progression (NHS England 2020a): https://www.england.nhs.uk/ournhspeople/online-version/new-ways-of-working-and-delivering-care/making-the-most-of-the-skills-in-our-teams/. An example of band 4 competencies and duties for the delivery of virtual PR is appended (Appendix 5). Supporting staff to develop motivational interviewing skills can ensure teams are supporting the Making Every Contact Count (MECC) agenda and supporting increased uptake of PR (Health Education England 2020a). Staff training and support resources are detailed within the ‘Resources for remote delivery’ section of this document.

Utilising staff who may be shielding for remote assessments and interventions has been implemented by a number of services; this has increased capacity and ensured continuation of service delivery. A number of teams have opened this opportunity to shielding staff who may not routinely work within the PR service, but following appropriate training and upskilling, this has enabled staff to be utilised in direct patient care and enabled service to continue to run.

There is a large and potential under-utilised resource from the student physiotherapy body. Placements have been cancelled in some areas and changed significantly in others (CSP COVID-19 survey 2020). Students can be utilised (again with training and development of an educator) to support the delivery of remote interventions. They are a highly trained and dedicated future workforce that could be mobilised to support the PR delivery. ‘What makes a great placement’ in the context of the COVID-19 response including virtual healthcare delivery and placement models has been considered by the CSP (CSP 2020c): www.csp.org.uk/frontline/article/student-placements.

Resources for remote delivery

The pandemic has seen a rapid shift to remote consultation in primary and secondary care with the aim of reducing unnecessary face-to-face attendances; serving to accelerate work associated with the widespread implementation of technology-enabled care (NHSX, 2020b). Using local trusts’ pre-existing digital facilities has several benefits including: staff familiarity, reduce training costs, use of existing authentication processes and data management protocols (NCSC, 2020). Healthcare professionals must adhere to their local trust’s clinical and information governance guidance in the use of remote delivery platforms. This section provides an overview of the available resources for the remote delivery of PR. Part two of this guidance document will cover further detail and evaluation of platforms for remote delivery.

Video conferencing platforms

• Microsoft Teams (replacing Skype for Business): www.microsoft.com/en-gb/microsoft
-365/microsoft-teams/group-chat-software.

• Allows you to host audio, video, and web conferences with anyone inside or outside your organisation.

• Servers based in EU rather than US which helps with GDPR compliance.

• Requires purchase of Office 365: Business Essentials (£3.80/user/month), Business Premium (£9.40/user/month).

• Attend Anywhere: www.attendanywhere.org.uk.

• Your Trust must register via NHS Improvement to get access.

• Zoom: https://zoom.us.

• Basic free plan: unlimited 1:1 meetings, limited to 40 minutes on group meetings, up to 100 participants.

• Paid plans are available including Zoom for healthcare: https://zoom.us/healthcare.

• Webex: www.webex.com.

• Basic free plan: unlimited meetings with up to 100 participants, unlimited time per meeting.

• Paid plans are available including Webex for telehealth: www.webex.com/industries/healthcare.html.

• OneConsultation: https://modalitysystems.com/software/oneconsultation-healthcare/.

• Fully managed and customisable virtual consultation service using Microsoft 365 technology.

• One-month free trial available.

• accuRx: www.accurx.com.

• Free services include: individual text messaging, video consultation, digital documents, medical surveys.

• Paid plan (accuRx plus) includes: patient triage, batch messaging and appointment reminders, wider range of surveys.

(Gardiner et al. 2020a; NHSX 2020b).

Web-based platforms

• myCOPD: www.nhs.uk/apps-library/mycopd/.

• Online COPD self-management app platform comprising education programmes, inhaler technique videos, weather/pollution alerts, and home rehabilitation classes (6-week graduated programme).

• Commissioned in some areas (free access for patients with COPD). Able to purchase myCOPD license via App Store/Google play for one-off payment of £39.99.

• Related evidence: Bourne et al. 2017.

• SPACE for COPD: www.spaceforcopd.co.uk.

• Self-management Programme of Activity, Coping and Education for COPD: manual and online self-management programme.

• Contains a range of educational topics including: information about medication, breathing control, exercise and nutritional advice. Individuals are encouraged to set goals and progress through a prescribed exercise programme and achieve weekly targets.

• Additional features include a glossary, frequently asked questions, a moderated discussion forum, an ‘Ask the expert’ facility which provides email access to a multi-professional team of experts, and a news blog (University Hospitals of Leicester NHS Trust 2020).

• Contact via website to register for paid access to manual and/or online programme.

• Related evidence: Chaplin et al. 2017; Horton et al. 2018; Bourne et al. 2020.

• The Innovation Agency (2020) present digital options seeking to improve the patient’s experience of PR. Examples include remote-monitoring (for example, CliniTouch Vie) and exercise prescription apps (for example, Rehab Guru); further information can be found on their website (Innovation Agency 2020): www.innovationagencynwc.nhs.uk/innovation-insight-pulmonary-rehabilitation.

Education resources

• ACPRC: Patient information leaflets (ACPRC 2011): www.acprc.org.uk/publications/patient
-information-leaflets/.

• Asthma UK: www.asthma.org.uk/advice/inhaler-videos.

• British Lung Foundation (BLF): www.blf.org.uk/support-for-you.

• Stay Active and Stay Well (BLF 2017): www.blf.org.uk/support-for-you/keep-active/exercise-video.

• Coronavirus and COVID-19 (BLF 2020): www.blf.org.uk/support-for-you/coronavirus.

• British Thoracic Society:

• PR resource pack (Gardiner et al. 2020b): www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/.

• European Lung Foundation (ELF): www.europeanlung.org/en/lung-disease-and
-information/lung-diseases/.

• Living well with COPD: www.livingwellwithcopd.com.

• Lung Foundation Australia: https://pulmonaryrehab.com.au/importance-of-education/education-topics/.

• myope: www.nhs.uk/apps-library/mycopd/.

• SPACE for COPD: www.spaceforcopd.co.uk/.

Staff training and support resources

Managing health and well-being:

• https://people.nhs.uk (NHS Leadership Academy 2020).

• www.england.nhs.uk/ournhspeople/online-version/lfaop/support-during-covid/ (NHS England, 2020b).

• www.acprc.org.uk/resources/covid-19-information/self-care-for-staff/ (ACPRC 2020).

Supporting redeployment and upskilling:

• www.england.nhs.uk/ournhspeople/online-version/new-ways-of-working-and-delivering-care/making-the-most-of-the-skills-in-our-teams/ (NHS England 2020a).

• www.e-lfh.org.uk/programmes/covid-19-recovery-and-rehabilitation/ (Health Education England 2020b).

• www.nhsx.nhs.uk/covid-19-response/technology-nhs/web-based-platform-which-offers-video-calls-services/ (NHSX 2020b).

• www.vc.scot.nhs.uk (NHS Scotland 2020).

• www.makingeverycontactcount.co.uk (Health Education England 2020a).

• Free training is available: www.eventbrite.co.uk/e/register-your-interest-introduction-to-motivational-interviewing-202021-tickets-56111935309.

Other resources

Coronavirus guidance for clinicians and NHS managers:

• www.england.nhs.uk/coronavirus/?priority-taxon=774cee22-d896-44c1-a611-e3109cce8eae (NHS England and NHS Improvement 2020).

PR SOP examples:

• www.respiratoryfutures.org.uk/resources/regional-and-local-resources/pulmonary
-rehabilitation-standard-operating-procedures-sops/.

Managing questionnaires online:

• LimeSurvey: www.limesurvey.org/en/.

• Free online survey software (paid plans available).

• Microsoft Forms: www.microsoft.com/en-gb/microsoft-365/online-surveys-polls-quizzes.

• Requires purchase of Office 365.

• Can be used for surveys, polls, and quizzes.

• REDCap: www.project-redcap.org.

• Secure web application for building and managing online surveys and databases. Some PR services are using this to distribute their assessment questionnaires to patients.

Student placement guidance:

• www.csp.org.uk/professional-clinical/practice-based-learning (CSP 2020c).

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